In a society obsessed with being happy, the emotion
of sadness has been turned into a private disease, a symbol of
failure. Catherine Keenan explores a problem that won't go away.
Samuel Beckett once observed that the tears of the world are a
constant quantity. Sadness can be ameliorated or ignored, but
we can never do away with it entirely. It is unavoidable and universal,
the one emotion that most profoundly tells us we are alive. Without
sadness, we wouldn't know the value of being happy.

Yet we have become so clumsy at handling this
elemental feeling. Other cultures have rituals, like wearing black
for a year, which make unhappiness acceptable in the public realm.
But we have no such codes, and sadness is too often regarded as
a shameful condition that we do not know how to admit into our
lives. If someone bursts into tears, our first reaction is often
to lead them away somewhere private. We will talk to anyone about
our happiness, but we tend to keep sadness to ourselves: it's
not polite to bring other people down. Too often, the old adage
holds: laugh and the world laughs with you, cry and you cry alone.

This is most obvious in times of extreme sorrow.
When Don's eldest daughter, Karen, died suddenly at the age of
20, his grief was cavernous. But in the following weeks it was
compounded because nobody wanted to talk about what had happened.
Scared of the emotional outpouring they might provoke, friends
were reluctant even to say Karen's name. Soon they stopped phoning,
or dropping round. One person crossed to the other side of the
road simply to avoid having to say hello. Sadness enveloped Don
and his wife, and people shunned them as if it were a disease.

Their grief was treated as an illness in other
ways too. Following award guidelines, Don was given three days'
compassionate leave to get over the death of his daughter. To
get more time, he needed a medical certificate, so he went to
a doctor and was offered antidepressants. Don thought his sadness
was normal rather than pathological, but he accepted the drugs
anyway. He stopped taking them when he decided they were cauterising
his normal reactions and not allowing him to properly grieve.

This was 15 years ago, and since then stories
like Don's have become more and more familiar. The co-director
of the Bereavement Care Centre, Mal McKissock, says that half
the people he sees have been offered antidepressants. Don puts
the figure even higher, saying almost all the bereaved parents
he has met have been offered drugs to assuage their pain.

Sometimes this is necessary grief can trigger
depressive episodes. But there is no doubt that at least some
of these people were simply experiencing natural sadness. Not
all sadness is this profound, and not everyone finds their friends
and family turn away. Women and younger people, in particular,
are much more likely to find that others are willing to talk about
it. But any society that deems it reasonable for people to return
to work two or three days after the death of an immediate family
member is clearly leaving too little room for grief.

The unhappy consequence is that too much of our
sadness is ending up in doctors' waiting rooms. Even psychiatrists
admit that this happens, though they emphasise it is in a minority
of cases. The prescription of antidepressants has skyrocketed
in Australia in the past 20 years. In 1991, depression was the
10th most frequently diagnosed condition in general medical practice;
by 1998 it had become the fourth, with about 700,000 new episodes
diagnosed every year. This is roughly in keeping with other Western
countries. The use of antidepressants in Britain has doubled in
the past decade; in the United States it is estimated that up
to 10 per cent of the population takes antidepressants.

There is no doubt this has been of enormous benefit
to some people. The development of new types of antidepressants,
such as Prozac, has made the treatment of depression easier and
less painful, and awareness campaigns worldwide, such as Beyond
Blue in Australia, have helped de-stigmatise mental illness so
that more people are getting the treatment they need. Even so,
health professionals insist there are still hundreds of thousands
of people who are suffering crippling depression in silence.

It is largely for the sake of these people that
psychiatrists and others are reluctant to talk about the medicalisation
of sadness. There is a group of people being over-treated for
depression, but there is another group being under-treated and
psychiatrists don't want to discourage them from coming forward
by conflating their condition with sadness. It may be true that,
as Lewis Wolpert, a biology professor and depression sufferer,
has put it, ``Sadness is to depression what normal growth is to
cancer." But in practice, the line between the two is shifting
and unclear, and we have always had difficulty telling them apart.

As far back as Aristotle's time, people used
the words melancholy and melancholia to refer simultaneously to
a passing, natural mood and to a debilitating mental condition.
Both terms are derived from the Greek words melas (black) and
khole (bile), a reference to Hippocrates's theory that health
subsisted in the correct balance of the four humours: blood, phlegm,
black bile and yellow bile. The presence of some black bile, and
its occasional ascendancy, was the sign of a healthy disposition.
But too much melancholy, and a person tipped over into mental
disturbance.

The humoural theory of health persisted for almost
2,000 years. Consequently, as Jennifer Radden writes at the opening
of her history The Nature of Melancholy (Oxford University Press):
``For most of western European history, melancholy was a central
cultural idea, focusing, explaining, and organising the way people
saw the world and one another and framing social, medical, and
epistemological norms."

It was only in the late 19th century, as psychiatry
became a recognised sub-discipline of medical practice, that this
idea began to fade from view. A clear distinction emerged between
melancholy as a mood or disposition, and melancholia, thought
of as a pathology. Soon after, however, both terms began to disappear.
Melancholy, with its connotations of creativity, sensitivity,
and authenticity, began its slow dissipation as it ceded ground
to more prosaic sadness. Melancholia was erased much more quickly
as the new word ``depression" emerged to replace it in psychiatric
nosology.

But Radden argues that there is no simple equivalence
between the two. The new designation of depression roughly coincided
with a new way of understanding the condition, which she traces
to Sigmund Freud. Although he continued to use the older term,
it was with his 1917 paper ``Mourning and Melancholia" that
our current notion of depression emerged, as he replaced an emphasis
on anxiety and extreme sadness with an emphasis on self-loathing
and introjected feelings of loss. It was Freud, more than anyone,
who made depression qualitatively different from ordinary sadness.

Persistent feelings of worthlessness are still
at the heart of definitions of depression. But as psychiatry has
cemented its place within empirical medicine, it has also tended
to emphasise functionality and more readily observable symptoms,
such as sleeplessness, loss of appetite and lack of energy. This,
combined with the qualified success of antidepressants, developed
in the 1940s, firmed up the sense of depression as an illness
like any other.

But this delineation from sadness has since become
more than a little unstuck. There are many possible reasons. Once
psychiatry became the repository of our mental ills, its purview
began to expand, and in the past 30 years ever more specific and
trivial subsets of depression have appeared. Leaving aside manic,
or bipolar, depression, the bible of the American Psychiatric
Association, the Diagnostic and Statistical Manual of Mental Disorders,
first divided depression into major disorders (lasting more than
two weeks) and minor disorders (one or two weeks). Now it also
includes dysthymic disorder (too mild to be called depression,
but extending over at least two years); subsyndromal depression
(for those who meet only some of the criteria for other types
of depression); depressive personality disorder (again too mild
for other categories); psychotic depression (with anti-social
indications); and recurrent brief depression (lasting only days,
but reappearing over a 12-month cycle).

Professor Gordon Parker, head of the school of
psychiatry at the University of NSW, and Professor Philip Boyce,
of the University of Sydney, agree that this ever-widening definition
has cast the net too wide. Inevitably, it allows natural grief
and sadness to be regarded as treatable conditions, and risks
robbing depression of any real meaning.

Both professors also note that pharmaceutical
companies benefit the most from this. Americans alone are estimated
to spend about $US890million ($1.7billion) every year on antidepressants:
the wider the range of indications, the more this billion-dollar
industry will expand.

Antidepressants are only effective for about
70 per cent of people, but unfortunately they are too often seen
as a quick fix. For most Australians, a GP is the first port of
call if they feel overwhelmed by sadness; sometimes, as in Don's
case, this is not through choice but necessity. But the average
GP appointment is five to six minutes, nowhere near enough time
to determine if a person's grief is appropriate to their circumstances,
so handing out pills is the easiest option.

Interestingly, this happens more often to women
than men. In her history, Radden notes that just as melancholy
was aligned with profundity and genius by Aristotle in the classical
period, by Ficino in the Renaissance, and by poets such as Keats
during the Romantic period so, too, was it regarded for 2,000
years as a male affliction. Women only started to suffer from
melancholia at the end of the 19th century, when the pathology
was isolated from the mood. As Radden puts it: ``Human, redeeming,
ambiguous (and masculine) melancholy" pulled apart from ``aberrant,
barren, mute (and feminine) depression". Women are still
diagnosed with depression at twice the rate of men.

Many explanations have been offered for this.
Some say women lead more difficult lives, others argue it is because
women are more likely than men to seek help for their pain. A
third and more disturbing explanation is that a predominantly
masculine medical establishment is more likely to view the feminine
expression of difficult emotions as aberrant.

It would be unfair, however, simply to blame
doctors. They could not diagnose hundreds of thousands of people
with depression every year if vast numbers were not coming to
them complaining about how they feel. Where once we saw a priest,
a relative, or a friend, many of us now take our pain to the doctor.
If they are treating that pain as illness, more of us are seeing
it that way, too.

This is evident in the very language we use.
Sad is a small word to describe what can be a tidal feeling. Depressed
seems to gather our gloom more fully, the syllables themselves
expressive of the weight we feel. Depressed also places our emotions
on a medical spectrum, aligning them not with events or natural
cycles of mood, but with ungovernable changes in brain chemistry.
Depressed allows us to stop searching for reasons and cause. It
gives us the luxury of handing over our emotional wellbeing to
a trained professional.

There is a special relief in this because, as
Don discovered, the unhappy truth is that we aren't very good
at dealing with sadness ourselves. How we reached this impasse
is a matter of conjecture, but it is almost certainly a function
of an increasingly rationalist society. McKissock notes that the
disintegration of the extended family leaves us more isolated,
and we are often wary of the intimacy that is required to listen
to someone else's sadness. In particular, it can make us confront
unhappiness of our own, something we don't necessarily want to
do.

But he also suggests it is because our society
is founded on the illusion of control. In the way that we direct
everything from the temperature in our homes to the trajectory
of our careers, we also want to control our emotions, be it through
a seven-step program or a pill. Progress seems to make us think
we can eliminate sadness and risk from our lives, and the court
system has become clogged by people who view difficult events
as aberrations for which someone must be to blame. When the disruptive,
unpredictable power of sadness erupts into our lives, it is a
problem like the car breaking down, which we think someone ought
to be able to fix. It is interesting that when grief washed over
America in the aftermath of the September 11 attacks, a group
of 20 psychologists felt it necessary to place an advertisement
telling people not to seek counselling or other help. They thought
we needed reminding of the simple, ineradicable fact that sadness
is part of life.

That, it seems, is what we refuse to accept.
Robert Burton, the great 17th-century writer on melancholy, wrote:
``'tis most absurd and ridiculous for any mortal man to look for
a perpetual tenor of happiness in this life." But knowing
this has never stopped people trying, and contemporary society
seems particularly intent on making happiness the rule. Perhaps
it is because we no longer have religion, which promises spiritual
rewards for a good life, that we now seem to value the happy life
above all things.

Unlike other generations, we are also offered
a bewildering and conflicting array of ways of achieving it. We
are promised happiness in everything from new cars to deodorant
and holidays. It is proffered to us on every billboard, in every
television commercial and on endless magazine covers. In the absence
of any other reason for being, happiness takes on the character
of a religion and sadness is pushed firmly aside. If happiness
is the goal, then unhappiness becomes a kind of failure, and succumbing
to it is akin to letting the side down. Even strangers in lifts
feel entitled to tell people to cheer up, it cannot be that bad.

Whatever its cause, there is no doubt that our
denial of unhappiness has a huge social cost. As Don discovered,
it isolates us when we are most in need of intimacy and adds to
grief the burdens of shame and incomprehension. Antidepressants
can help those who are depressed, but like psychotherapies, all
they do for the sad is whittle away autonomy and decrease resilience.
Worst of all, by shutting out sadness and hiving it off as a pathology,
we diminish our sense of what it means to be human.

The extent to which we can give ourselves up
to sadness determines how fully we can experience joy. In his
extraordinary book The Noonday Demon (Chatto&Windus), Andrew
Solomon writes that despite its almost unbearable pain, it was
only in depression that ``I learned my own acreage, the full extent
of my soul".

By medicalising sadness, we also run the risk
of forgetting its redemptive power. Aristotle thought melancholy
men the wittiest, and marvelled that anyone who had become outstanding
in philosophy, statesmanship, poetry and the arts was tinged with
more than a touch of black bile. Some of these men probably had
what we now call depression, and there can be little doubt they
would have traded all their achievements for the sweet relief
of modern pills. But to wish away sadness, too, is to wish for
a fool's paradise.

It is telling that the word melancholy has fallen
into virtual disuse. It seems better to remind us that sadness
is what stretches us, what spurs us on to create, and urges us
to seek out meaning for our lives. It reminds us that mild unhappiness
can be a gently pleasurable state of contemplation and quiet truths.
Burton said melancholy was many things: sad, sour, damn'd, harsh,
fierce and divine. But above all else, he knew there was ``none
so sweet as melancholy".

depressioNet.com.au
would like to acknowledge the support of the Sydney Morning Herald
for Australians suffering depression, by allowing us to reproduce
this article within depressioNet.com.au.